Implementacin del registro de cncer de base poblacional de la ciudad de Mrida en Mxico: procesos y resultados preliminares

Texto completo

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Leal YA, Reynoso-Noverón N, Aguilar-Castillejos LF, Meneses-García A, Mohar A, Piñeros M. Implementation of the population-based cancer registry in the city of Mérida, Mexico: process and early results. Salud Publica Mex. 2020;62:96-104.

https://doi.org/10.21149/10501

Implementation of the population-based

cancer registry in the city of Mérida,

Mexico: process and early results

Yelda A Leal, PhD,(1) Nancy Reynoso-Noverón, MD, PhD,(2) Luis Fernando Aguilar-Castillejos, MD,(3)

Abelardo Meneses-García, MD, PhD,(4) Alejandro Mohar, MD, PhD,(2) Marion Piñeros, MD.(5)

Leal YA, Reynoso-Noverón N, Aguilar-Castillejos LF, Meneses-García A, Mohar A, Piñeros M.

Implementación del registro de cáncer de

base poblacional de la ciudad de Mérida en México: procesos y resultados preliminares.

Salud Publica Mex. 2020;62:96-104.

https://doi.org/10.21149/10501

(1) Centro Institucional de Capacitación y Registro de Cáncer, Unidad Médica de Alta Especialidad, Instituto Mexicano del Seguro Social. Mérida, Mexico. (2) Unidad de Investigación Biomédica en Cáncer, Instituto Nacional de Cancerología-Universidad Nacional Autónoma de México. Mexico City, Mexico. (3) Hospital de Especialidades Star Médica. Mérida, Yucatán, Mexico.

(4) Dirección, Instituto Nacional de Cancerología. Mexico City, Mexico.

(5) Sección de Vigilancia del Cáncer, Agencia Internacional para la Investigación en Cáncer. Lyon, France.

Received on: April 10, 2019 • Accepted on: July 8, 2019

Corresponding author: PhD. Yelda A. Leal. Registro Poblacional de Cáncer Mérida, Unidad Médica de Alta Especialidad del Centro Médico Nacional Ignacio García Téllez, Instituto Mexicano del Seguro Social. Calle 34, núm. 439 x 41, col. Industrial. 97150 Mérida, Mexico.

E-mail: yelda.leal@imss.gob.mx

Abstract

Objective. To briefly describe the process of establishment and preliminary results of the Mérida Population-based Can-cer Registry (Mérida-PBCR) Materials and methods. Mérida-PBCR started in 2016 as a research project in the IMSS, with a gradual increase in its information sources. It covers a population of 908 536 inhabitants. Data collection is active and passive, international standards are used; CanReg5 software enables data entry, storage and analysis. Results. Current data include 71.5% of sources. For the period 2015-2016, a total of 2 623 new cancer cases were registered, the majority of these (60.1%) among females. 81.5% of the cases had morphological verification. Prostate (17.4%), colorectal (8.5%) and stomach (8.1%) cancers were the most common among males, and breast (31.6%), cervix (12%) and corpus uteri (7.6%) cancers, the most common among females. Age-adjusted cancer incidence rates (per 100 000) for all sites combined were 114.9 among males and 145.1 among females. Conclusion. The implementation of the Mérida-PBCR has followed particular parameters, with important efforts to include new information sources. Although the data are still preliminary and must be interpreted with great caution, the main cancers follow a similar pattern to that of the national and regional estimates.

Keywords: neoplasms; registry; non-communicable diseases; Mexico

Resumen

Objetivo. Describir brevemente el proceso de implemen-tación y resultados preliminares del Registro de Cáncer de Base Poblacional (RCBP) de Mérida. Material y méto-dos. RCBP-Mérida inició en 2016 como un proyecto de investigación del IMSS, con cobertura poblacional de 908 536 habitantes. El número de fuentes de información ha incrementado gradualmente. Se realizó colección de datos de forma pasiva y activa en software CanReg5 utilizando estándares internacionales. Resultados. Se han incluido al RCBP-Mérida 71.5% de las fuentes de información. Durante 2015-2016 se registraron 2 623 casos nuevos, la mayoría (60.1%) mujeres. El 81.5% de los casos tuvo verificación morfológica. En hombres, el cáncer de próstata (17.4%), colorrectal (8.5%) y estómago (8.1%) son los más comunes; en mujeres, mama (31.6%), cérvix (12.0%) y cuerpo-uterino (7.6%). Las tasas de incidencia ajustadas por edad (100 000 habitantes) para todos los sitios combinados son 114.9 hombres y 145.1 mujeres. Conclusión. La implementación del RCBP-Mérida ha seguido parámetros particulares, con importante esfuerzo para incluir fuentes de información. Aunque los datos son preliminares y se deben interpretar con precaución; los principales tipos de cáncer siguen un patrón similar a las estimaciones nacionales y regionales

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E

stablishing sound cancer control plans is necessary to overcome the growing cancer burden; within them, population-based cancer registries (PBCR) play an essential role in the planning and evaluation of the activities.1,2 Accordingly, incidence by type of cancer

has been established as a key indicator in the Monitor-ing Framework on Non-Communicable Diseases of the World Health Organization (WHO),3 and its collected

information has been reaffirmed at the more recent 70th

World Health Assembly.4 Despite PBCR being the only

means to obtain cancer incidence and survival at the population level, there are enormous disparities in their coverage and quality among regions of the world.2,5 In

Latin America, the PBCR included in the last volume (XI) of the serial publication Cancer Incidence in Five Continents represents less than 10% of the population.6

Mexico, the second most populated country in Latin America, has made various attempts to establish cancer registries. One of the first initiatives dates back to 1975, when the Jalisco State Cancer Registry was initi-ated; nevertheless, until very recent developments and changes, it has been mainly a pathology–based registry.7

In 1982, the first attempt to establish a national cancer registry had an active participation of 34 hospitals of Mexico City, extending to the states of Jalisco and Nuevo León. This initiative was replaced in 1994, by the Na-tional Histopathological Cancer Registry, an effort that lasted only until 2001.8,9 Additional developments worth

mentioning have been the Pediatric Cancer Registry led by the XXI Century National Medical Center of the Mexican Institute for Social Security (Instituto Mexicano del Seguro Social, IMSS), which covers circa 65% of the Mexican population; this registry covers pediatric pa-tients of various states affiliated to IMSS.10

More recently, under the leadership of the Na-tional Cancer Institute of Mexico (Incan), the country has advanced simultaneously in the establishment of a national cancer control plan and a network of sub-national PBCRs that conform the so-called National Cancer Registry. The Senate of the country created the National Cancer Registry by a law that will be further regulated.11 Upon signature of an agreement with

the Incan, the Global Initiative for Cancer Registry Development (GICR) led by the International Agency for Research on Cancer (IARC) has supported cancer registration during the last years, providing assistance to the PBCR of Mérida (in the state of Yucatán) and Jalisco, amongst others.12

Herein, we present a brief overview of key aspects of the establishment of the PBCR in Mérida and the pre-liminary results achieved so far for the years 2015-2016.

Materials and methods

The population covered by the registry is 908 536 in-habitants of the city of Mérida (figure 1).13 Mérida is the

capital and most populated city of the state of Yucatán, in the Southeast of the country. It concentrates the on-cological services in the state.

Organization

The Mérida PBCR started in 2016 as a research project financed by the IMSS and the National Council for Science and Technology (Conacyt) after a short stay of the Cancer Registry Director at IARC. The project was approved by the National Research Commission-IMSS number R-2014-785-085. From the beginning, the office of the registry has been located at the IMSS’s high-spe-cialty medical unit (UMAE)-IMSS hospital in Mérida.14

Information sources

For the inclusion of information sources, the sanitary census of the city of Mérida was reviewed, and estab-lishments visited by cancer patients for diagnosis, treat-ment and follow-up were selected; each of theme was corroborated through a telephone call or a visit in situ, and was invited to collaborate with the Mérida-PBCR. Table I presents the sources of information by type of source and year of inclusion. The expansion of data sources for the registry has been decidedly supported and facilitated by the Incan and the IMSS, with visits and advocacy to some of the institutions to be included, particularly during 2016 and 2017.

Case definition

The registry includes all new cancer cases diagnosed in residents of Mérida since January 1st, 2015; the date of

diagnosis is applied as defined by the European Network of Cancer Registries (ENCR).15 The case definition includes,

in addition to all malignant neoplasms, non-malignant tumors of the brain and the central nervous system. Resi-dence is considered when the patient had been living there for more than six months and also had the official ID with a Mérida address to endorse it.

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Data collection

An ad hoc data collection format was designed as part of the project to collect the socio-demographic, tumor and source information as suggested by IARC.5 Data

collection is both active and passive. Registrars (mainly nurses) actively visit the information sources to abstract the cancer cases from the clinical records. Some institu-tions provide consolidated databases, in which case the registrars review a subset of clinical records for diagnostic verification and complementary information if required. Cases of non-melanoma skin cancer are not actively sought.

Death certificates are obtained annually in electronic format from the Yucatán Ministry of Health Office. They include information regarding deaths certified in the state of Yucatán. All information is validated before being capture into the system with particular attention to the residence status in Mérida and the metropolitan area.

Processes and quality control

A Manual of procedures was written at the start of the registry and has been reviewed during the external site visits. Coding follows the International Classification of Diseases for Oncology (ICD-O-3).16 For data entry,

qual-ity checks and data analysis, the registry uses CanReg5, IARC’s free software, which facilitates identification of duplicates and of the use of non-existent codes, and

also verifies internal consistency by applying standard validations.17 Main data quality indicators, e.g. the

per-centage of cases with microscopic verification (MV%) and percentage of cases notified by death certificate only (DCO%) are also obtained using the CanReg analysis. The CanReg5 program was used to estimate the age-standardized incidence rates (ASR) per 100 000 inhabit-ants, using the direct method and the world standard population.18 All information is handled according to

national confidentiality guidelines.19,20 No legal

frame-work for cancer registration was existent at the moment of initiation.

Training

During a short mentorship stay at IARC, the cancer registry director received training for setting up the PBCR; however, most of the registrars have received their training at the workplace. The team has attended several online training courses organized by the IARC Regional Hub for Latin America, and the registry direc-tor participated in a regional training course on data analysis for cancer registries.

External support

Through the GICR, two expert site visits to the Mérida PBCR took place during 2016 and 2017 respectively; visits were accompanied with specific

recommenda-100 + 95-99 90-94 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 1-4 0

Male (2015-2016) Female (2015-2016)

64 295 853 1 836 3 298 5 214 7 884 11 628 15 3367 18 400 22 747 28 384 31 259 32 936 33 451 37 219 39 237 36 603 37 006 36 926 29 472 7 510 157 582 1 467 2 938 4 936 7 171 10 178 14 249 18 769 22 039 26 096 31 573 34 762 36 520 35 481 37 793 38 967 35 798 35 447 35 526 27 965 7 127

10 9 8 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 10

Percentage Percentage

Figure 1. PoPulationPyramid. mérida, yucatán, mexico, 2015-2016

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tions and a particular emphasis to expand data sources. One site visit included in-depth support for CanReg5. Periodic communication between Incan, GICR and the registry director has taken place since inception.

Results

Implementation process

Data for 2015 and 2016 are presented, with collection closed in December 2018. Table I describes inclusion and access to public and private health care institu-tions. Briefly, at the beginning of 2016 we started on three sources of the IMSS

the high-specialty medical unit (UMAE) host of the registry and two general hospitals

; at the end of the first year of operation of the Mérida-PBCR, seven sources had been included (five public, non-IMSS, and two private); in 2017 we further incorporated 19 establishments (three public), and a larger number of sources was included in 2018. Table II shows the number of new cancer cases by (first) institution; in 2015-2016, 39.7% of the new cancer cases included were from the institution hosting the cancer registry.

Preliminary results

During 2015-2016 a total of 2 623 new cancer cases (excluding non-melanoma skin cancer) were registered, the majority of which occurred in females (60.1%) (ta-bles III and IV). For both sexes combined, the number of new cancer cases in 2016 increased by 52% compared with 2015; this increase was stronger among females, amounting to 68% of the new cancer cases between the two years (information not shown). For 2015-2016 the cancer incidence rates (age-standardized per 100 000) for all cancers combined (except non-melanoma skin cancer) were 114.9 for males, and 145.1 for females.

Among males, prostate cancer amounted to 17.4% of the new cancer cases, with an ASR of 20.3 per 100 000, followed by colorectal cancer (8.5%; ASR of 9.5 per 100 000) and stomach cancer (8.1%; ASR 9.0 per 100 000) (table III). Among females, breast cancer was the most commonly diagnosed cancer type, amounting to 31.6% of the new cancer cases, with an ASR per 100 000 of 45.1 per 100 000. It was followed by cervical cancer (12% and ASR of 17 per 100 000) and by corpus (7.6% and ASR of 11.2 per 100 000) (table IV). Childhood cancers (0-16) accounted for 106 cases representing 4% of all new can-cer cases, the majority (54 cases) among boys (51%); the most affected age were infants 1-4 years old, with 39.6% of cases. Distribution according to the International Classification of Chilhood Cancer (ICCC) diagnostic

Table I

numberoFinFormationsources

includedbyyear. mérida, yucatán, mexico

Source by type

Number of sources by year of inclusion 2016 2017 2018 Total

High- specialized hospital 2 1 0 3

General hospital 5 2 4 11

Specialized oncology clinic 0 1 0 1

Chemotherapy clinic 0 1 1 2

Radiotherapy clinic 0 0 1 1

Specialized hospital 0 1 1 2

Alternative clinic 0 0 1 1

Pathology lab 0 2 3 5

Imaging detection clinic 0 0 1 1

Nuclear medicine lab 0 1 2 3

Oncologists and hematologists 0 5 10 15

Urologist 0 2 10 12

Neurologists and neurosurgeons 0 2 9 11

Pneumologists 0 0 4 4

Gastroenterologists and proctologists 0 0 11 11

Gynecologists and colposcopy 0 0 6 6

Administrative office 0 1 1 2

Total 7 19 65 91

groups21 showed that the majority were leukemias,

myeloproliferative and myelodysplastic diseases, with 44 cases (41.5%); lymphomas and reticuloendothelial neoplasms, with 16 cases (15.1%), and malignant bone tumors, with 11 cases (10.4%).

Regarding indices of data quality, 78.8% of the cases among males and 84.1% among females were microscopically verified; 14.9% and 10.1% of the cases among males and females respectively, were diagnosed by death certificate only.

Discussion

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Table II

numberoFnewcancercases, byFirstmainsource. mérida cancer registry, mexico (2015-2016)

Source Source by type Sub-systemHealth 2015 2016 2015-2016 n % n % n %

1 Highly specialized hospital 1 IMSS 437 42.3 604 38.0 1041 39.7

2 General hospital 1 IMSS 70 6.8 142 8.9 212 8.1

3 General hospital 2 IMSS 10 1.0 12 0.8 22 0.8

4 General hospital 3 IMSS 3 0.3 6 0.4 9 0.3

5 Specialized oncology clinic Red Cross 19 1.8 7 0.4 26 1.0

6 General hospital 4 MoH 27 2.6 84 5.3 111 4.2

7 Highly specialized hospital 2 MoH 1 0.1 3 0.2 4 0.2

8 Specialized clinic MoH 0 0.0 1 0.1 1 0.0

9 General hospital 5 MoH 79 7.7 123 7.7 202 7.7

10 General hospital 6 ISSSTE 55 5.3 86 5.4 141 5.4

11 Administrative office MoH 168 16.3 368 23.1 536 20.4

12 Alternative clinic Private 1 0.1 9 0.6 10 0.4

13 General hospital 7 Private 41 4.0 39 2.5 80 3.0

14 Pathology lab 1 Private 26 2.5 17 1.1 43 1.6

15 Pathology lab 2 Private 19 1.8 11 0.7 30 1.1

16 Specialized hospital 2 Private 1 0.1 0 0.00 1 0.0

17 Chemotherapy clinic Private 4 0.4 10 0.6 14 0.5

18 Pathology lab 3 Private 1 0.1 1 0.1 2 0.1

19 Pathology lab 4 Private 2 0.2 1 0.1 3 0.1

20 Pathology lab 5 Private 36 3.5 19 1.2 55 2.1

21 Urological clinic Private 3 0.3 2 0.1 5 0.2

22 Pathology lab 6 Private 0 0.0 2 0.1 2 0.1

23 Imaging detection clinic 1 Private 2 0.2 0 0.00 2 0.1

24 Imaging detection clinic 2 Private 2 0.2 22 1.4 24 0.9

25 General hospital 8 Private 24 2.3 12 0.8 36 1.4

26 Radiotherapy clinic Private 0 0.0 5 0.3 5 0.2

27 General hospital 9 Private 1 0.1 2 0.1 3 0.1

28 Imaging detection clinic 3 Private 0 0.0 1 0.1 1 0.0

29 Nuclear medicine lab 1 Private 0 0.0 2 0.1 2 0.1

Total All 1 032 100.0 1 591 100.0 2 623 100.0

IMSS: Mexican Institute for Social Security (Instituto Mexicano del Seguro Social) MoH: Ministry of Health

ISSSTE: Security and Social Services Institute for State Workers (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado)

It is not usual or recommended to start a PBCR as a research project, yet this has been reported also for a Colombian registry.22 Although this may be an

interesting option for starting operations and providing

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subsequently became a PBCR. Nevertheless, we wish to stress that the aim was always to establish a PBCR with a very limited number of variables that would hardly comply with those required for an HBCR; we do not recommend starting an HBCR in order to convert it to a PBCR.5 In case of the Mérida PBCR,

the initial data collection at the hospital hosting the registry facilitated capacity building and acquisition of specific skills, such as case abstraction and coding, among registrars. Starting the registration at the UMAE Mérida has favored the capture of significant number of cases, as the IMSS is the largest provider of medi-cal care in Mexico.14 The fact that, at the start of the

Mérida PBCR, no legal framework existed to support cancer registration in the country, along with the lack of experience of the operation of this type of cancer registry, delayed the inclusion of other institutions as

data sources, particularly those not pertaining to the IMSS’ health system (where the registry started). As mentioned above, the launching of the Mérida PBCR required important efforts by the registry director, as well as support from both local and national institu-tions like Incan, the Ministry of Health of Yucatán, and the IMSS.

Despite the difficulties and associated efforts to expand data collection to new information sources, it must nevertheless be recognized that in this case the most important sources in terms of the number of cases were included already from the start. The high propor-tion of cases from the institupropor-tion that hosted the registry is consistent with its level of high specialization, given that it is the sole institution of its kind in the city, and with the 60% coverage of Mexican population by the IMSS.14

Table III

newcancercases, incidencerates (asr Per 100 000) andqualityindicatorsbycancersite,

males. mérida cancer registry, mexico (2015-2016)

Cancer site Cases Freq (%) Crude Rate ASR MV (%) DCO (%) ICD10

Mouth and pharynx 20 1.9 2.3 2.1 80.0 10.0 C00−14

Esophagus 21 2.0 2.4 2.2 85.7 14.3 C15

Stomach 84 8.1 9.5 9.0 80.9 11.9 C16

Colon, rectum, anus 89 8.5 10.1 9.5 88.8 5.6 C18−21

Liver 75 7.2 8.5 8.3 54.7 38.7 C22

Pancreas 22 2.1 2.5 2.5 59.1 22.7 C25

Larynx 28 2.7 3.2 3.1 75.0 14.3 C32

Lung, trachea, bronchus 54 5.2 6.1 5.8 68.5 20.3 C33−34

Pleura and other thoracic 3 0.3 0.3 0.3 100.0 0.0 C37−38

Melanoma of skin 10 1.0 1.1 1.1 70.0 30.0 C43

Prostate 181 17.4 20.6 20.3 79.6 13.8 C61

Testis 31 2.9 3.5 3.3 80.6 9.7 C62

Kidney and urinary NOS 46 4.4 5.2 5.1 76.1 13.0 C64−66,68

Bladder 35 3.4 3.9 3.9 85.7 8.6 C67

Brain and nervous system 28 2.7 3.2 3.2 82.1 10.7 C70−72

Thyroid 12 1.2 1.4 1.3 83.3 16.7 C73

Ill−defined 53 5.1 5.8 5.8 67.9 28.3 C76−80

Other cancers 112 10.7 12.3 10.8 86.6 6.3 C17,23-24, 26, 31, 39-41,45-49,60, 63, 69,74-75, 86

Lymphoma 81 7.8 9.2 8.6 86.4 9.8 C81−85,90,88,96

Leukemia 57 5.5 6.5 6.8 75.4 21.1 C91−95

All sites but C44 1 042 100 118.4 114.9 78.8 14.9 ALLbC44

ASR: age standardized rate MV: microscopic verification DCO: death certificate only

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The Mérida PBCR has met the international stan-dards since its inception; the quality data indicators obtained so far are comparable with those of many of the neighboring countries.6 Data analysis and

consis-tency checks have been greatly facilitated by the use of CanReg5.

The involvement of the Incan and of the GICR, via a formal agreement, in an early phase of the implementa-tion of the registry has strengthened commitment, col-laboration, and periodic communication. Partnerships are key to support different aspects of cancer control programs and cancer surveillance; concrete examples of partnership involvement in cancer registration in the region have been highlighted before.23-25 In addition,

mentoring and tailored support –critical components of the GICR (http://gicr.iarc.fr/en/)– are crucial ingredi-ents for success in knowledge transfer.12

Cancer incidence results for Mérida during this period need to be taken with extreme caution and must be validated once full coverage of the PBCR has been achieved and the registry operations have become stabilized. The cancer incidence rates (per 100 000) observed in Mérida during 2015-2016 for all cancers combined among females (ASR of 145.1) are similar to the estimated rates for Mexico in Globocan 2018 (ASR 149.6); among males, they were much lower (ASR 114.9 versus 136.5) compared to estimates Globocan 2018 (ASR per 100 000). Nevertheless, the distribution of the

Table IV

newcancercases, incidencerates (asr Per 100 000) andqualityindicatorsbycancersite,

Females. mérida cancer registry, mexico (2015-2016)

Cancer site Cases Freq (%) Crude Rate ASR MV (%) DCO(%) ICD10

Mouth & pharynx 7 0.4 0.7 0.6 100.0 0.0 C00−14

Esophagus 9 0.6 1.0 0.8 77.8 11.1 C15

Stomach 63 4.0 6.7 5.6 76.2 15.9 C16

Colon, rectum, anus 74 4.7 7.9 6.4 93.2 6.8 C18−21

Liver 52 3.3 5.5 4.5 59.6 28.9 C22

Pancreas 21 1.3 2.2 1.8 57.1 28.6 C25

Larynx 8 0.5 0.9 0.8 87.5 12.5 C32

Lung, trachea, bronchus 29 1.8 3.1 2.7 65.5 20.7 C33−34

Pleura and other thoracic 7 0.4 0.8 0.5 85.7 14.3 C37−38

Melanoma of skin 14 1.0 1.5 1.2 100.0 0.0 C43

Breast 499 31.6 53.3 45.1 88.0 5.0 C50

Cervix 188 12.0 20.1 17.0 87.2 9.0 C53

Corpus and uterus NOS 120 7.6 12.8 11.2 87.5 4.2 C54−55

Ovary and adnexa 78 4.9 8.3 7.2 79.5 11.5 C56

Kidney and urinary NOS 39 2.5 4.2 3.7 76.9 15.4 C64−66,68

Bladder 19 1.2 2.0 1.7 89.5 5.3 C67

Brain and nervous system 16 1.0 1.7 1.8 75.0 18.8 C70−72

Thyroid 55 3.5 5.9 5.0 92.7 5.5 C73

Ill−defined 59 3.7 6.5 5.4 71.2 27.1 C76−80

Other Cancers 113 7.2 12.4 7.2 81.4 12.4 41,45, C48-49,51-52,57,

C17,23-24,30-31,40-C6, 74-75

Lymphoma 69 4.4 6.4 6.9 91.3 7.3 C81−85,90,88,96

Leukemia 42 2.6 4.5 4.8 73.8 23.8 C91−95

All sites but C44 1 581 100 168.8 145.1 84.1 10.1 ALLbC44

ASR: age standardized rate MV: microscopic verification DCO: death certificate only

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most common cancers (prostate, breast and cervix) and the overall quality indices are consistent with local and regional reports.6,26

Furthermore, findings like the sex disparity –with 66% of cases occurring in females, in whom mouth, pharynx and melanoma skin cancers were all micro-scopically verified– clearly indicate limitations in cover-age. Although these limitations are being tackled with the current inclusion of 91 information sources in the registry, there is a need to evaluate whether case findings include radiology departments with tomography.

The high percentage of pediatric cancers (4%) among the male population probably also reflects un-derregistration among males of all ages. Notably, the percentage of lymphomas in children (15.1%) has been also documented by Fajardo-Gutierrez and colleagues for the Yucatán state and deserves further investiga-tion.27 The most frequent pediatric cancer, as expected,

was acute leukemia, which in Mexico can be diagnosed at an early stage and therefore can have better opportu-nities for survival.28,29

Conclusion

Beyond the described limitations, the present report provides an important input to guide the establish-ment of the cancer registry network that is currently underway in Mexico. At the same time, advances have motivated the approval of the Cancer Registry Law by the Congress in 2017, which will provide an unprecedented support for the registry network. We underscore the importance of commencing directly as a PBCR supported by the current Mexican legal frame-work and securing a budgetary line. While results need to be interpreted with extreme caution, this first report clearly highlights the efforts made to achieve sustainability, coverage, and quality within interna-tional standards. Continuous collaboration of local health care providers, local and national authorities, and international partners should allow attainment of these objectives in the near future.

Acknowledgements

The authors wish to express their gratitude for the sup-port received from the National Council for Science and Technology (Conacyt-PDCPN-2014/248635) and the Health Research Fund of the Mexican Institute of Social Security (Fondo de Investigación en Salud del Instituto Mexicano del Seguro Social, FIS/IMSS/Prot/2014/1395) for carrying out the present work. PBCR-Mérida is deeply grateful to Dr. Mendoza-Mezquita for his com-mitment and support in the development of this project.

The authors are grateful to the Mérida cancer registry team, FunSalud, and Patronato del Incan. PBCR-Mérida deeply thanks Dr. Vargas-Becerra, of the Health Re-search Council-IMSS, for his critical review.

Conflict of interest. The authors declare that they have no conflict of interest. Where authors are identified as personnel of the International Agency for Research on Cancer / World Health Organization, the authors alone are responsible for the views expressed in this article, which do not necessarily represent the decisions, policies or views of the International Agency for Research on Cancer / World Health Organization.

References

1. Parkin DM. The role of cancer registries in cancer control. Int J Clin Oncol. 2008;13(2):102-11. https://doi.org/10.1007/s10147-008-0762-6 2. Piñeros M, Znaor A, Mery L, Bray F. A global cancer surveillance framework within noncommunicable disease surveillance: making the case for population-based cancer registries. Epidemiol Rev. 2017;39(1):161-9. https://doi.org/10.1093/epirev/mxx003

3. World Health Organization. Draft comprehensive global monitoring framework and targets for the prevention and control of NCDs. Geneva: World Health Organization, 2013 [cited March 21, 2018]. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_8-en.pdf 4. World Health Organization. Seventieth world health assembly (WHA70) cancer prevention and control in the context of an integrated approach. Geneva: World Health Organization, 2017 [cited February 26, 2019]. Avail-able from: http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_R12-en.pdf 5. Bray F, Znaor A, Cueva P, Korir A, Swaminathan R. Planning and devel-oping population-based cancer registration in low-and-middle income settings. Technical Report 43. Lyon: International Agency for Research on Cancer, 2014 [cited Nov 13, 2019]. Available from: http://www.rho.org/ files/IARC_Planning_developing_cancer_registries_2014.pdf

6. Bray F, Colombet M, Mery L, Piñeros M, Znaor A, Zanetti R, et al. Cancer incidence in five continents. IARC Scientific Publication No. 166. Lyon: IARC, 2017 [cited June 21, 2018]. Available from: http://ci5.iarc.fr 7. Secretaría de Salud de Jalisco. Registro estatal de cáncer en Jalisco [in-ternet]. Guadalajara: Gobierno del Estado de Jalisco, 2014 [cited February 26 2019]. Available from: https://ssj.jalisco.gob.mx/registros/51

8. Barroso E, Rendón J, Medina R, Mora T, De la Mora S. Registro Nacional de Cáncer. Estado Actual y Perspectivas. Rev Inst Nal Cancer. 1986;32:190-213.

9. Macías-Martínez CG, Kuri-Morales P. Resultados del Registro Histopa-tológico de Neoplasias en México 1995. Gac Med Mex. 1998;134:337-42. 10. Allende-López A, Fajardo-Gutiérrez A. Historia del registro de cáncer en México. Rev Med Inst Mex Seguro Soc. 2011;(S1):49.

11. Secretaría de Salud. Decreto por el que se adicionan diversas disposi-ciones de la Ley General de Salud. Mexico City: Secretaría de Salud, 2017 [cited May 30, 2018]. Available from: http://www.dof.gob.mx//avisos/2598/ SALUD_220617/SALUD_220617.html

12. International Agency for Research on Cancer. Global initiative for cancer registry development (GIRC). Lyon: IARC, 2019 [cited February 2019]. Available from: http://gicr.iarc.fr/

13. National Institute of Statistic and Geography (INEGI). State govern-ment of Yucatán. México: INEGI, 2010 [cited Jun 30, 2018]. Available from: http://www.yucatan.gob.mx/p=perfil_demografico

(9)

http://publications.iarc.fr/Book-And-Report-Series/Iarc-Technical-Publica-tions/Standards-And-Guidelines-For-Cancer-Registration-In-Europe-2003 16. Fritz A, Percy CL, Jack A, Shanmugaratnam K, Sobin L, Parkin DM, et al. International classification of diseases for oncology. 3rd ed. Geneva: World Health Organization, 2000.

17. Ferlay J, Burkhard C, Whelan S, Parkin DM. Check and conversion pro-grams for cancer registries (IARC tools for cancer registries). Technical Report 42. Lyon: International Agency for Research on Cancer, 2005. 18. Ahmad OB, Boschi-Pinto C, Lopez A, Murray CJL, Lozano R, Inoue M. Age standardization of rates: a new WHO standard. Geneva: World Health Organization, 2001.

19. Secretaría de Gobernación. Ley federal de protección de datos per-sonales en posesión de los particulares. Mexico City: Diario Oficial de la Federación, 2010 [cited February 2019]. Available from: http://dof.gob.mx/ nota_detalle.php?codigo=5150631&fecha=05/07/2010

20. Gobierno del Estado de Yucatán. Reglamento interior del Instituto Estatal de Transparencia, Acceso a la Información Pública y Protección de Datos Personales. In: Diario Oficial del Gobierno del Estado de Yucatán. Mérida: Gobierno del Estado de Yucatán, 2017 [cited February 2019]. Available from: http://www.inaipyucatan.org.mx/transparencia/Portals/0/ pdf/reglamentoleyes/reglamentointerior09oct17.pdf

21. Steliarova-Foucher E, Stiller C, Lacour B, Kaatsch P. International clas-sification of childhood cancer. 3rd edition. Cancer. 2005;103(7):1457-67. https://doi.org/10.1002/cncr.20910

22. Pardo C, Bravo LE, Uribe C, López G, Yépez M, Navarro E, et al. Comprehensive assessment of population-based cancer registries: an experience in Colombia. J Registry Manag. 2014;41(3):128-34. 23. Trapido EJ, Borras JM, Burton R, Samiei M, Elwood M. ICCC-3 Session F Group. Critical factors influencing the establishment, maintenance

and sustainability of population-based cancer control programs. Tumori. 2009;95(5):637-45. https://doi.org/10.1177/030089160909500506 24. Frech S, Muha CA, Stevens LM, Trimble EL, Brew R, Perin DP, et al. Per-spectives on strengthening cancer research and control in Latin America through partnerships and diplomacy: experience of the National Cancer Institute’s Center for global health. J Glob Oncol. 2018;4:1-11. https://doi. org/10.1200/jgo.17.00149

25. Piñeros M, Frech S, Frazier L, Laversanne M, Barnoya J, Garrido C, et

al. Advancing reliable data for cancer control in the Central America four region. J Glob Oncol. 2018;4:1-11. https://doi.org/10.1200/jgo.2016.008227 26. Bray F, Piñeros M. Cancer patterns, trends and projections in Latin America and the Caribbean: a global context. Salud Publica Mex. 2016;58(2):104-17. https://doi.org/10.21149/spm.v58i2.7779 27. Fajardo-Gutiérrez A, Juárez-Ocaña S, González-Miranda G, Palma-Padilla V, Carreón-Cruz R, Ortega-Álvarez MC, et al. Incidence of cancer in children residing in ten jurisdictions of the Mexican Republic: importance of the Cancer registry (a population-based study). BMC Cancer. 2007;7:68. https://doi.org/10.1186/1471-2407-7-68

28. Fajardo-Gutiérrez A, González-Miranda G, Pachuca-Vázquez A, Allen-de-López A, Fajardo-Yamamoto LM, Rendón-Macías ME. Cancer incidence and mortality in children in the Mexican Social Security Institute (1996-2013). Salud Publica Mex. 2016;58(2):162-70. https://doi.org/10.21149/ spm.v58i2.7785

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Table II

Table II

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Table III

Table III

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Table IV

Table IV

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